Director of clinical proteomics JACC 2017;70:1785 guidelines · Elevated Lp(a), CKD, symptomatic...
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Transcript of Director of clinical proteomics JACC 2017;70:1785 guidelines · Elevated Lp(a), CKD, symptomatic...
FOR THE EXAMINE
JACC 2017;70:1785 guidelines
Robert Chilton
Professor of Medicine
University of Texas Health Science Center
Director of Cardiac Catheterization labs
Director of clinical proteomics
Patients who require <25% additional lowering
of LDL-C, patients with recent ACS <3 months
Cost considerations with recent availability of generic
ezetimibe and future cost savings, ease of use as oral agent
with low pill burden, patient preferences, heart failure,
hypertension, age >75 years, diabetes, stroke, CABG, PAD,
eGFR <60 ml/min/1.73 m2, and smoking.
JACC 2017;70:1785 guidelines
Clinical ASCVD and comorbidities require
>25% additional lowering of LDL-C, a PCSK9 inhibitor
may be preferred as the initial non-statin agent.
The….
clinician–patient discussion should consider the extent of
available scientific evidence for net ASCVD risk- reduction
benefit, cost, administration by subcutaneous injection,
every 14-day or monthly dosing schedule, and storage
requirements (refrigeration).
PCSK-9 inhibitor
JACC 2017;70:1785 guidelines
•
Diabetes,
Recent (<3 months) ASCVD event
ASCVD event while already taking a statin
Poorly controlled other major ASCVD risk factors
Elevated Lp(a), CKD, symptomatic heart failure
Baseline LDL-C >190 mg/dL not due to secondary causes
Hemodialysis
Prior MI, stroke, CABG
Currently smoking
Symptomatic PAD
Cath >40% stenosis in >2 vessels
HDL <40
hsCRP >2
Metabolic syndrome1
These patients should be treated
first with maximally tolerated statin intensity.
If patients have a >50% reduction in LDL-C from baseline
(and may consider LDL-C <70 mg/dL or non–HDL-C <100
mg/dL)
Continue the statin therapy and continue
to monitor adherence to medications and lifestyle, and
ongoing LDL-C response to therapy.
Patients who are unable to tolerate
even a moderate-intensity statin should be evaluated for
statin intolerance and considered for referral to a lipid
specialist.1
1 JACC 2017;70:1785 guidelines
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YES met goal
JACC 2017;70:1785 guidelines
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Mechanism of action: Inhibits Niemann-Pick C1 like 1
(NPC1L1) protein; reduces cholesterol absorption in
small intestine
Adverse effects: Monotherapy—upper respiratory
tract infection, diarrhea, arthralgia, sinusitis, pain in
extremity; combination
with statin—nasopharyngitis, myalgia, upper
respiratory tract infection, arthralgia, diarrhea.
Drug–drug interactions: cyclosporine, fibrates, BAS
IMPROVE-IT -- (The addition of ezetimibe to moderate-intensity statin
in patients with recent ACS resulted
in incremental lowering of LDL-C and reduced primary composite
endpoint of CV death, nonfatal MI, UA requiring
re-hospitalization, coronary revascularization [$30 days after
randomization], or nonfatal stroke. The median follow-up was
6 years.)
SHARP --(Simvastatin plus ezetimibe reduced LDL-C and reduced
primary endpoint of first major ASCVD event
[nonfatal MI or CHD death, non-hemorrhagic stroke, or any arterial
revascularization procedure] compared to placebo over a
median f/u of 4.9 years).
Mechanism of action: Human monoclonal antibody to PCSK9. Binds
to PCSK9 and increases the number of LDL receptors
available to clear circulating LDL
Adverse effects: Alirocumab—nasopharyngitis, injection site
reactions, influenza. Evolocumab—nasopharyngitis, upper
respiratory tract infection, influenza, back pain, and injection site
reactions.
No evidence of increase in cognitive adverse effects
observed in FOURIER or EBBINGHAUS